During this period, the risk of opioid overdose deaths among former inmates was 40 times higher than the general population; for heroin overdose deaths specifically, that risk shot up to 74 times the general population’s and remained elevated at up to 18 times the risk for a full year after release.

Part of the way the United States has addressed the opioid epidemic is by cracking down on drug-related activities, including prosecuting low-level drug offenders and treating drug overdoses as homicides.

“The result is that we incarcerate people instead of treating their substance use disorders that led to the conditions for arrest,” said Shabbar Ranapurwala, an epidemiologist at the UNC Gillings School of Global Public Health and lead author of the study.

In 2015, there were 6.7 million individuals who were either incarcerated or receiving correctional supervision in the U.S., according to the Bureau of Justice Statistics. And two-thirds of those incarcerated had a pre-existing substance use disorder when they entered the system.

Former inmates are at a higher risk of overdose than the general drug-using population because prison typically includes forced abstinence from drugs without complementary care like medication-assisted treatment and few post-prison treatment resources. That means people leave prison with a low tolerance for drugs and no plan for treating their underlying addiction.

But Ranapurwala noted that the changing nature of the opioid epidemic has made the problem for the formerly incarcerated even more complicated.

Most fatal drug overdoses today involve the synthetic opioid fentanyl, which is 30 to 50 times more powerful than heroin. That means that in addition to inmates having a low drug tolerance, people who used opioids before entering prison may be especially unprepared for the more potent varieties that are widely available and used today if they relapse.

A Call For Addiction Treatment Behind Bars

Although substance use disorders are classified as mental health conditions, the vast majority of correctional facilities don’t have addiction treatment programs, meaning inmates are left to detox on their own and aren’t connected to resources to help them maintain sobriety upon release.

“In effect, the criminal justice system only facilitates the removal of people with substance use disorders out of our society, rather than acting as a truly rehabilitative space,” said Ranapurwala.

But later releasing people with substance use disorder who have never been treated sets them up to fail at sobriety.

“If you just dump people out and they’re at a huge risk of addiction — they’re also at risk of committing crimes to feed that addiction, and at risk of showing up in the emergency room,” said Arthur Caplan, the founding director of New York University’s Division of Medical Ethics.

Instead, Caplan said, we should be treating inmates for opioid addiction while they are incarcerated.

“I’d manage [addiction] the same way I would a person who was at risk of a heart attack or a stroke,” Caplan said, noting since addiction is a chronic medical condition, it should be managed as such, regardless of whether or not the person with addiction is behind bars.

Treatment behind bars, coupled with overdose education and distribution of the drug overdose antidote naloxone, are two key strategies that could help reduce deaths among former inmates, the study authors note.

A Treatment Experiment In Rhode Island

Places that have implemented those kinds of policies have already achieved favorable public health outcomes. Between 2016 and 2017, Rhode Island’s Department of Corrections screened every person entering the system for opioid addiction and offered them their choice of three medication-assisted opioid treatments ― buprenorphine, methadone or naltrexone ― while incarcerated. Upon release, former inmates had access to continuing treatment.

The result was that the overdose death rate of recently released inmates fell by 61 percent, according to a research letter published this year in JAMA Psychiatry. Rhode Island itself saw a 12 percent decline in opioid overdose deaths during the same one-year period.

“It’s the first time in a long time that we’ve seen meaningful population-level changes,” Traci Green, lead author of that study and associate professor of emergency medicine and epidemiology at Brown University, told Tonic in February.

A separate study, published this week in PLOS Medicine, found that study participants in British Columbia with past criminal convictions were five times less likely to die from infectious disease and three times less likely to die from drug overdoses during periods where they were prescribed methadone.

But scaling up a program like Rhode Island is likely a ways off, with only about 40 of the nation’s 5,000 local, state and federal correctional facilities incorporating sustained medication-assisted treatment into their facilities, the authors of the American Journal of Public Health study noted.

Ranapurwala stressed that while the medical community knows that substance use disorder is a mental health condition, the U.S. has focused on incarcerating individuals with addiction instead of treating them.

“We’ve been notorious about punishing addiction, as opposed to preventing or treating it,” Caplan said.